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Tarsia M, Vitale A, Gaggiano C, Sota J, Maselli A, Bellantonio C, Guerriero S, Dammacco R, La Torre F, Ragab G, Hegazy MT, Fonollosa A, Paroli MP, Del Giudice E, Maggio MC, Cattalini M, Fotis L, Conti G, Mauro A, Civino A, Diomeda F, de-la-Torre A, Cifuentes-González C, Tharwat S, Hernández-Rodríguez J, Gómez-Caverzaschi V, Pelegrín L, Babu K, Gupta V, Minoia F, Ruscitti P, Costi S, Breda L, La Bella S, Conforti A, Mazzei MA, Carreño E, Amin RH, Grosso S, Frediani B, Tosi GM, Balistreri A, Cantarini L, Fabiani C. Effectiveness and Safety of Biosimilars in Pediatric Non-infectious Uveitis: Real-Life Data from the International AIDA Network Uveitis Registry. Ophthalmol Ther 2024; 13:761-774. [PMID: 38206518 PMCID: PMC10853125 DOI: 10.1007/s40123-023-00863-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/23/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Since many biological drug patents have expired, biosimilar agents (BIOs) have been developed; however, there are still some reservations in their use, especially in childhood. The aim of the current study is to evaluate the efficacy and safety of tumor necrosis factor (TNF) inhibitors BIOs as treatment for pediatric non-infectious uveitis (NIU). METHODS Data from pediatric patients with NIU treated with TNF inhibitors BIOs were drawn from the international AutoInflammatory Disease Alliance (AIDA) registries dedicated to uveitis and Behçet's disease. The effectiveness and safety of BIOs were assessed in terms of frequency of relapses, risk for developing ocular flares, best-corrected visual acuity (BCVA), glucocorticoids (GCs)-sparing effect, drug survival, frequency of ocular complications, and adverse drug event (AE). RESULTS Forty-seven patients (77 affected eyes) were enrolled. The BIOs employed were adalimumab (ADA) (89.4%), etanercept (ETA) (5.3%), and infliximab (IFX) (5.3%). The number of relapses 12 months prior to BIOs and at last follow-up was 282.14 and 52.43 per 100 patients/year. The relative risk of developing ocular flares before BIOs introduction compared to the period following the start of BIOs was 4.49 (95% confidence interval [CI] 3.38-5.98, p = 0.004). The number needed to treat (NNT) for ocular flares was 3.53. Median BCVA was maintained during the whole BIOs treatment (p = 0.92). A significant GCs-sparing effect was observed throughout the treatment period (p = 0.002). The estimated drug retention rate (DRR) at 12-, 24-, and 36-month follow-up were 92.7, 83.3, and 70.8%, respectively. The risk rate for developing structural ocular complications was 89.9/100 patients/year before starting BIOs and 12.7/100 patients/year during BIOs treatment, with a risk ratio of new ocular complications without BIOs of 7.1 (CI 3.4-14.9, p = 0.0003). Three minor AEs were reported. CONCLUSIONS TNF inhibitors BIOs are effective in reducing the number of ocular uveitis relapses, preserving visual acuity, allowing a significant GCs-sparing effect, and preventing structural ocular complications. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05200715.
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Affiliation(s)
- Maria Tarsia
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Carla Gaggiano
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Jurgen Sota
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Anna Maselli
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Chiara Bellantonio
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Silvana Guerriero
- Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
| | - Rosanna Dammacco
- Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
| | - Francesco La Torre
- Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, 70126, Bari, Italy
| | - Gaafar Ragab
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University (NGU), Giza, Egypt
| | - Mohamed Tharwat Hegazy
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt
- Faculty of Medicine, Newgiza University (NGU), Giza, Egypt
| | - Alex Fonollosa
- Department of Ophthalmology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
| | - Maria Pia Paroli
- Uveitis Service, Ophthalmologic Unit, Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Emanuela Del Giudice
- Pediatric Rheumatology Unit, Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Maria Cristina Maggio
- University Department PROMISE "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Marco Cattalini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Lampros Fotis
- Third Department of Paediatrics, National and Kapodistrian University of Athens, General University Hospital "Attikon", Athens, Greece
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit with Dialysis, Department of Human Pathology in Adulthood and Childhood "G. Barresi", AOU Policlinic "G. Martino", Messina University, Messina, Italy
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli-Sacco Hospital, Piazzale Principessa Clotilde, 20121, Milan, Italy
| | - Adele Civino
- Pediatric Rheumatology and Immunology Unit, Vito Fazzi Hospital, 73100, Lecce, Italy
| | - Federico Diomeda
- Pediatric Rheumatology and Immunology Unit, Vito Fazzi Hospital, 73100, Lecce, Italy
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Cifuentes-González
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Samar Tharwat
- Rheumatology and Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Mansoura University, El Gomhouria St, Mansoura, Dakahlia Governorate, Egypt
| | - José Hernández-Rodríguez
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Verónica Gómez-Caverzaschi
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Pelegrín
- Unidad Clínica de Enfermedades Autoinflamatorias y Grupo de Investigación en Vasculitis, Servicio de Enfermedades Autoimmunes, Hospital Clínic de Barcelona, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Kalpana Babu
- Department of Uveitis and Ocular Inflammation, Vittala International Institute of Ophthalmology and Prabha Eye Clinic and Research Centre, Bengaluru, Karnataka, India
| | - Vishali Gupta
- Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Francesca Minoia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Delta 6 Building, PO Box 67100, L'Aquila, Italy
| | | | - Luciana Breda
- Department of Paediatrics, University of Chieti-Pescara, Chieti, Italy
| | - Saverio La Bella
- Department of Paediatrics, University of Chieti-Pescara, Chieti, Italy
| | | | - Maria Antonietta Mazzei
- Unit of Diagnostic Imaging, Department of Medical, Surgical and Neuro Sciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, 53100, Siena, Italy
| | - Ester Carreño
- Department of Ophthalmology, Hospital Universitario Rey Juan Carlos, Madrid, Spain
- Department of Ophthalmology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Rana Hussein Amin
- Opthalmology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Salvatore Grosso
- Clinical Paediatrics, Department of Molecular Medicine and Development, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Gian Marco Tosi
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, ERN RITA Center, Policlinico "Le Scotte", University of Siena, Viale Bracci 16, 53100, Siena, Italy
| | - Alberto Balistreri
- Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, ERN RITA Center, Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
| | - Claudia Fabiani
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, ERN RITA Center, Policlinico "Le Scotte", University of Siena, Viale Bracci 16, 53100, Siena, Italy.
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Leal I, Steeples LR, Wong SW, Giuffrè C, Pockar S, Sharma V, Green EKY, Payne J, Jones NP, Chieng ASE, Ashworth J. Update on the systemic management of noninfectious uveitis in children and adolescents. Surv Ophthalmol 2024; 69:103-121. [PMID: 36682467 DOI: 10.1016/j.survophthal.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/22/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Noninfectious uveitis (NIU) in children and adolescents is a rare but treatable cause of visual impairment in children. Treatments for pediatric NIU and their side effects, along with the risks of vision loss and the need for long-term disease monitoring, pose significant challenges for young patients and their families. Treatment includes local and systemic approaches and this review will focus on systemic therapies that encompass corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and biological disease-modifying antirheumatic drugs (bDMARD). Treatment is generally planned in a stepwise approach. Methotrexate is well-established as the preferential csDMARD in pediatric NIU. Adalimumab, an antitumor necrosis factor (TNF) agent, is the only bDMARD formally approved for pediatric NIU and has a good safety and efficacy profile. Biosimilars are gaining increasing visibility in the treatment of pediatric NIU. Other bDMARD with some evidence in literature for the treatment of pediatric NIU include infliximab, tocilizumab, abatacept, rituximab and, more recently, Janus kinase inhibitors. Important aspects of managing children on these systemic therapies include vaccination issues, risk of infection, and psychological distress. Also, strategies need to address regarding primary nonresponse/secondary loss of response to anti-TNF treatment, biological switching, and monitoring regimens for these drugs. Optimal management of pediatric uveitis involves a multidisciplinary team, including specialist pediatric uveitis and rheumatology nurses, pediatric rheumatologists, psychological support, orthoptic and optometry support, and play specialists.
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Affiliation(s)
- Inês Leal
- Ophthalmology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Visual Sciences Study Centre, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
| | - Laura R Steeples
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Academic Health Science Centre, Manchester, UK
| | - Shiao Wei Wong
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Chiara Giuffrè
- Centro Europeo di Oftalmologia, Palermo, Italy; Ophthalmology Department, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Sasa Pockar
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Vinod Sharma
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Elspeth K Y Green
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Janine Payne
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Nicholas P Jones
- School of Biological Sciences, University of Manchester, Manchester, UK
| | | | - Jane Ashworth
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, UK; Division of Evolution & Genomic Sciences, University of Manchester, Manchester, UK
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Ulu K, Çakan M, Çağlayan Ş, Yiğit RE, Demir F, Coşkuner T, Kardeş E, Sözeri B. Real-life data on efficacy and safety of original Adalimumab and biosimilar Adalimumab (ABP 501) in pediatric rheumatic diseases. Expert Opin Biol Ther 2023; 23:833-839. [PMID: 36101926 DOI: 10.1080/14712598.2022.2123703] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/08/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND We aimed to compare the efficacy and safety of the original product (OP) and biosimilar product (BP) of adalimumab in pediatric rheumatic diseases. RESEARCH DESIGN AND METHODS The study group consisted of patients who had received original or biosimilar adalimumab (ABP 501) therapy for at least 3 months. The patients were divided into uveitis and arthritis groups based on the indication of adalimumab treatment. Assessment of disease activity was performed by Juvenile Arthritis Disease Activity Score in patients with juvenile idiopathic arthritis, and by standardization of uveitis nomenclature criteria in patients with uveitis. RESULTS The study included 140 patients, of which 87 were treated with OP and 53 with BP. In the arthritis group, 26 (63.4%) and 20 (57.1%) patients reached inactive disease according to JADAS-27 in the original and biosimilar adalimumab groups, respectively. In the uveitis group the mean number of exacerbations throughout the treatment period was 0.84 ± 1.07 in the OP group, and 0.58 ± 0.79 in the BP group. There were 71 treatment-emergent adverse events in the OP group and 38 in the BP group. CONCLUSION There was no significant difference between the biosimilar and the original product in efficacy and safety.
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Affiliation(s)
- Kadir Ulu
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Şengül Çağlayan
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Ramazan Emre Yiğit
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Ferhat Demir
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Taner Coşkuner
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Esra Kardeş
- Department of Ophthalmology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
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Demirkan FG, Sönmez HE, Lamot L, Akgün Ö, Sözeri B, Ayaz NA. Embracing Change: An International Survey Study on the Beliefs and Attitudes of Pediatric Rheumatologists Towards Biosimilars. BioDrugs 2022; 36:421-430. [PMID: 35380389 DOI: 10.1007/s40259-022-00526-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Biosimilars have been adopted by clinicians more slowly than anticipated in the post-marketing phase. OBJECTIVES We aimed to reveal the perceptions and attitudes of pediatric rheumatologists towards biosimilars and the obstacles to biosimilar therapy. METHODS A web-based survey designed to determine the knowledge, experience, and perceptions of pediatric rheumatologists about biosimilars was electronically mailed to the participants between April and August 2021. Responses were collected anonymously and subsequently analyzed. RESULTS A total of 114 pediatric rheumatologists including fellows (32.4%), specialists (29.8%), and seniors (37.7%) responded to the questionnaire. According to the data, 75 (65.8%) physicians had already prescribed at least one biosimilar. The vast majority of participants were aware of the potential cost savings of biosimilars (84, 73.3%). Participants who felt insufficiently informed were 41.8%, 67.6%, and 83.7% among seniors, specialists, and fellows, respectively. In pediatric rheumatology, the scarcity of clinical trials and real-life data (64%) and inadequate information about tolerance to the biosimilars and related side effects in children (49.1%) were the most common barriers expressed by prescribers. Nearly half (45%) of the pediatric rheumatologists preferred to prescribe biosimilars in the treatment of biologic-naive cases. However, most (93%) were reluctant to switch a reference molecule to a biosimilar while the patient was doing well under the originator medicine. CONCLUSIONS This survey provided insights into the concerns about prescribing biosimilars among pediatric rheumatologists. In the field of pediatric rheumatology, further education about biosimilars and real-life experiences is required to better inform about treatment options in children.
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Affiliation(s)
- Fatma Gül Demirkan
- Department of Pediatric Rheumatology, İstanbul University, İstanbul School of Medicine, Istanbul, Turkey
| | - Hafize Emine Sönmez
- Department of Pediatric Rheumatology, Kocaeli University, Kocaeli School of Medicine, Kocaeli, Turkey
| | - Lovro Lamot
- Department of Pediatrics, University Hospital Center, Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Özlem Akgün
- Department of Pediatric Rheumatology, İstanbul University, İstanbul School of Medicine, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Research and Training Hospital, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, İstanbul University, İstanbul School of Medicine, Istanbul, Turkey.
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Demirkan FG, Ulu K, Öztürk K, Karadağ ŞG, Özdel S, Sönmez HE, Çakmak F, Demir F, Sözeri B, Aktay Ayaz N. Toward the integration of biosimilars into pediatric rheumatology: adalimumab ABP 501 experience of PeRA research group. Expert Opin Biol Ther 2021; 22:197-202. [PMID: 34730483 DOI: 10.1080/14712598.2021.2002296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To review the real-life data, to provide an input to the literature concerning treatment of juvenile idiopathic arthritis (JIA) with adalimumab (ADL) biosimilar. METHOD This multi-centric retrospective study was conducted among children with JIA, followed up for at least 24-weeks from the initiation of ADL biosimilar (ABP 501) treatment. Adverse events and alterations in disease activity scores were figured out. RESULTS The median age of the group was 15.5 (5-18) years. JIA categories were oligoarticular (n =12), enthesitis-related (ERA) (n=24), psoriatic (PsA) (n=6), and polyarticular (n=4). Uveitis was detected at the initiation of the disease (n=3), during the disease course (n=5), or before the diagnosis (n=1). The first-line treatment preferences were ADL biosimilar (n=37) and etanercept (n=9). On the 6th month of ABP 501, 40 (86.9%) patients had achieved complete remission. Six patients (1 PsA, 1 polyarticular JIA, and 4 ERA) had ongoing active arthritis. Furthermore, all except one of the patients had remission of ophthalmologic findings. No life-threatening adverse events were observed. CONCLUSIONS ABP 501 has a gradual increase in prescription in pediatric rheumatology. Real-life data of the cohort announce that ADL biosimilar is a suitable and effective treatment option for patients with JIA in case of indication.
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Affiliation(s)
- Fatma Gül Demirkan
- Department of Pediatric Rheumatology, Istanbul University, Istanbul School of Medicine, İstanbul, Turkey
| | - Kadir Ulu
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Research and Training Hospital, Istanbul, Turkey
| | - Kübra Öztürk
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, School of Medicine, Goztepe Research and Training Hospital, Istanbul, Turkey
| | - Şerife Gül Karadağ
- Department of Pediatric Rheumatology, University of Health Sciences, Bakırköy Dr. SadiKonuk Training and Research Hospital, İstanbul, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, University of Health Sciences, Dr. Sami Ulus Obstetrics and Gynecology, Pediatric Health and Disease Training and Research Hospital, Ankara, Turkey
| | - Hafize Emine Sönmez
- Department of Pediatric Rheumatology, Kocaeli University, Kocaeli School of Medicine, Kocaeli, Turkey
| | - Figen Çakmak
- Department of Pediatric Rheumatology, Istanbul University, Istanbul School of Medicine, İstanbul, Turkey
| | - Ferhat Demir
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Research and Training Hospital, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Research and Training Hospital, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Istanbul University, Istanbul School of Medicine, İstanbul, Turkey
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